Holding on while letting go: trauma and growth on the pathway of dementia care in families

The matter of grief, loss and bereavement in families of those living and dying in residential aged care setting: A systematic review

The grief, loss and bereavement needs of the families of those living and dying in residential aged care setting is not very well understood. This systematic review examines grief, loss, and bereavement experience of, and interventions relating to, family caregivers of those entering, living and dying in residential aged care. Out of 2023 papers that were identified, 35 met the inclusion criteria which included (n=28) qualitative and (n=7) quantitative intervention studies. The qualitative findings indicated quality of care provided to the resident at the end of their life, and after death care influenced family caregivers' grief reactions. The intervention studies revealed that educational interventions have the potential to lead to some benefits in the context of grief loss and bereavement outcomes. Recognizing the emotional experiences and support needs of families and carers may enhance the understanding of the ageing, caring, dying, grieving pathway for older people and their families.

"You're the only thing he comes out [of his room] for": A qualitative study of engagement between Laughter Care Specialists and families of people with dementia in long-term care

OBJECTIVES

Family involvement in the lives of people who have dementia and live in long-term care is important, but family members may face challenges communicating and connecting with their loved one as dementia progresses. A type of therapeutic humor (Laughter Care) delivered by trained specialists aims to engage people with dementia who reside in long-term care through creative play and laughter. This study aimed to explore the perceptions of Laughter Care Specialists (LCSs) regarding families' engagement with the program.

METHODS

Semi-structured interviews were conducted with LCSs (n = 8) and analyzed inductively using thematic analysis.

RESULTS

Family members were reported to initially have varied degrees of openness toward Laughter Care, but often become more accepting after observing positive engagement with the person with dementia. Family members were perceived to benefit from the program through witnessing the person with dementia enjoy joyous and light interactions, learn new ways of communicating and connecting with the person with dementia, and engage in positive interactions at end of life.

SIGNIFICANCE OF RESULTS

Laughter Care may provide family members with novel ways of communicating and connecting with people who have dementia at end of life as well as comfort into bereavement.

Vigilance, risk, and service use among caregivers of people living with dementia

OBJECTIVE

The purpose of this investigation was to understand the dynamics among dementia caregiving, vigilance, and home and community-based service use.

METHODS

This paper is derived from a larger, mixed-methods study on caregiving. We used a descriptive qualitative approach to analyze interview data of 30 family caregivers of relatives with dementia.

RESULTS

We found five domains of vigilance in which caregivers felt "on duty": ensuring attentiveness, ensuring safety, ensuring resources, ensuring healthcare, and ensuring closeness. Formal service use did not necessarily give caregivers relief from vigilance, with the language of risk often employed by caregivers.

CONCLUSION

Because service use could contribute to feelings of vigilance, rather than give caregivers a break from a sense of watchfulness, these findings support calls for dementia-specific training for service providers. In future caregiving research, the relationship between vigilance, caregiver distress, and role captivity should be explored.

The effect of a performing arts intervention on caregivers of people with mild to moderately severe dementia

OBJECTIVES

This study aimed to determine the feasibility and acceptability of a multi-modal performing arts intervention (MPAI) for caregivers of people with mild to moderately severe dementia. The secondary objective was to examine how MPAI might change caregiver burden, caregiver resiliency, and perceived quality of life (QoL) for care recipients.

METHOD

The study features a mixed-methods design. Caregivers (N = 32) completed the Zarit Burden Interview (caregiver burden) Brief Resilience Scale (resiliency) and Quality of Life-Alzheimer's disease measure (care recipient QoL) at five study timepoints. Semi-structured interviews (N = 15) documented the intervention's acceptability and caregivers' subjective experiences. Feasibility was indexed through withdrawal and attendance analysis. Braun and Clarke (2006) thematic analysis guided the qualitative analysis.

RESULTS

Caregiver burden significantly declined from baseline through final follow-up. Caregiver resiliency and care recipient QoL were not significantly changed but trended up during the intervention until it dropped at the end of the program. Qualitative data suggests the reversal in resiliency and QoL may be explained by caregivers' increased anxiety as the program ended. Acceptability data indicated caregivers were unanimously highly satisfied with the intervention, desiring to continue participation. Feasibility findings provide recommendations for intervention improvements.

CONCLUSION

MPAI could reduce caregiver burden and increase resilience for informal caregivers of a person with dementia. Effects drop off quickly at the end of the program, indicating the need for ongoing interventions that provide social support, a respite from the pressures of care recipients' dependency, and the relief that caregivers experience when they perceive benefits to their care recipient's well-being.

Trust of Nursing Home Staff Caring for Residents with Advanced Dementia: A Qualitative Descriptive Study of Family Caregivers' Perspectives

BACKGROUND/OBJECTIVES

Studies of interpersonal trust within nursing homes (NHs) is limited. This study aimed to describe the perspectives of interpersonal trust in NH staff among family caregivers of residents with advanced dementia. Additionally, comparisons of Black and White caregivers' perspectives were also explored.

DESIGN

We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives.

PARTICIPANTS

Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis.

RESULTS/CONCLUSIONS

While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning.

DESIGN

We used data generated from a parent study, Assessment of Disparities and Variation for Alzheimer's disease Nursing home Care at End of life (ADVANCE) to examine the experience of trust from the family caregivers' perspectives.

PARTICIPANTS

Data generated from interviews with 44 family caregivers of residents with advanced dementia (Black n = 19 and White n = 25) were analyzed using thematic analysis.

RESULTS/CONCLUSIONS

While both Black and White family caregivers experienced trust and mistrust, Black caregivers more often experienced differential mistrust, trust for certain staff members and mistrust of others. As differential mistrust is a new concept relative to trust, additional research is required to elucidate its meaning.

The experiences, priorities, and perceptions of informal caregivers of people with dementia in nursing homes: A scoping review

BACKGROUND

Person-centered care has been shown to increase desired outcomes for people with dementia, yet informal caregivers' dissatisfaction with care is often reported. For those living in a nursing home, informal caregivers are uniquely situated to provide key insights into the individual's care. However, little is known of the informal caregivers' perspective, which hinders efforts to improve their satisfaction with person-centered nursing home care. Thus, we examined the comprehensive experiences, priorities, and perceptions of informal caregivers of nursing home residents with dementia.

METHODS

In collaboration with stakeholders, a scoping review of Medline (Ovid), EMBASE.com, CINAHL (EBSCO), the Cochrane Library (Wiley), and PsycINFO (Ovid) databases from January 2000 to July 2020 was conducted. Data were extracted reflecting the experiences, priorities, and preferences of caregivers of people with dementia residing in nursing homes.

RESULTS

We identified 114 articles that revealed nine themes: (1) communication, (2) transition to nursing home, (3) quality of care, (4) quality of life, (5) informal caregiver role, (6) knowledge of dementia, (7) end-of-life preferences, (8) medication use to manage neuropsychiatric behaviors, and (9) finances.

CONCLUSION

Informal caregivers described aspects of care that led to both positive and negative experiences with and perceptions of nursing home care. The shortcomings in communication were discussed most frequently, indicating a high priority area. While researchers define the identified themes individually, informal caregivers perceive them to be interwoven as they relate to person-centered care delivery. Although we did not assess the quality of included articles, by identifying themes relevant to caregivers' perspectives of nursing home care, our findings may help to inform efforts to optimize caregivers' satisfaction with nursing home care for residents with dementia.

Dementia families: Relinquishing home care to aged care services: Guilt, traumatic loss and growth

BACKGROUND AND OBJECTIVES

Few studies explore both negative and positive perspectives of family members who relinquish home care of a family member with dementia for systemic aged care.

RESEARCH DESIGN AND METHODS

This phenomenological study sought the 'lived' experience of relinquishing the role of home carer for a family member with mild to severe dementia to others within care home settings, by seeking to understand the impact of aged care on family members' psychological well-being. Using semi-structured interviews, positive and negative subjective interpretations from 17 families (27 individuals) provided data for analysis, following the protocols of interpretative phenomenological analysis.

RESULTS

One superordinate theme, mistrust/integrity, overarched oscillation between mistrust of the aged care system and a struggle for personal integrity in caring for these participants. Two sub-themes emerged: intrinsic trauma and extrinsic trauma. Intrinsic trauma explained feelings of helplessness and guilt, and internally directed responses that triggered a retreat into submission ultimately reducing the participant's role in advocacy. Extrinsic trauma represented externally directed responses such as anger and frustration, where family members became more engaged and watchful and recognised a need for vigilance and advocacy. Paradoxically oscillating between these personal struggles, participants exhibited growth, a third theme that defined assertive/advocacy utilised to nurture hope, gratitude, courage and change.

DISCUSSION AND IMPLICATIONS

Family members experienced complex distress as they relinquished home care to others within systemic aged care for a member with dementia. By developing adaptive responses as appropriate, for example, advocating for their family member or accepting compliance with treatment, collaborative care between family and staff created better outcomes for the family member with dementia.

Caring for older people with dementia reliving past trauma

BACKGROUND

The occurrence of behavioural changes and problems, and degree of paranoid thoughts, are significantly higher among people who have experienced extreme trauma such as during the Holocaust. People with dementia and traumatic past experiences may have flashbacks reminding them of these experiences, which is of relevance in caring situations. In nursing homes for people with dementia, nursing assistants are often the group of staff who provide help with personal needs. They have firsthand experience of care and managing the devastating outcomes of inadequate understanding of a person's past experiences.

AIM

The aim was to describe nursing assistants' experiences of caring for older people with dementia who have experienced Holocaust trauma.

RESEARCH DESIGN

A qualitative descriptive and inductive approach was used, including qualitative interviews and content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Nine nursing assistants from a Jewish nursing home were interviewed.

ETHICAL CONSIDERATIONS

The study was approved by the Regional Ethical Review Board, Stockholm.

FINDINGS

The theme 'Adapting and following the survivors' expression of their situation' was built on two categories: Knowing the life story enables adjustments in the care and Need for flexibility in managing emotional expressions.

DISCUSSION AND CONCLUSION

The world still witnesses genocidal violence and such traumatic experiences will therefore be reflected in different ways when caring for survivors with dementia in the future. Person-centred care and an awareness of the meaning of being a survivor of severe trauma make it possible to avoid negative triggers, and confirm emotions and comfort people during negative flashbacks in caring situations and environments. Nursing assistants' patience and empathy were supported by a wider understanding of the behaviour of people with dementia who have survived trauma.

Moderate dementia: relational social engagement (RSE) during family visits

OBJECTIVE

This qualitative study seeks evidence of retained social awareness in individuals with moderate dementia residing in care-homes, when engaged in interactive family visits.

METHOD

Speech/non-speech data collected from 10/15-minute video-recorded family interactions of five family groups (12 individuals; 2 sessions per family group) were coded using thematic analysis.

RESULTS

Interactional patterns embedded in familiar bonds provided the context for the superordinate theme: relational social engagement (RSE). This overarched two subthemes: in-step and out-of-step; highlighting that RSE, can occur as a result of both positive and negative familial communication patterns. When familial communication was in-step, despite changed communication pathways, the resident's attempts at social engagement appeared open, relaxed, and responsive. A sense of trust, and familiarity appeared to facilitate reciprocal understanding and the striving of resident family members to retain family group membership. When familial communication was out-of-step, active attempts at reciprocity or open engagement from visiting family members were not observed. At such times, communication became discordant, and frustrated in their efforts to remain an integral part of the family group, the resident appeared disinterested or guarded often retorting with annoyance at visiting family members.

CONCLUSION

The construct of RSE appears specific to prior meaningful relationships, where optimal social awareness and communication, positive and negative, can occur. Currently, dementia assessment and care does not include RSE during family interactions. Implications are discussed.

Severe dementia: relational social engagement (RSE) during family visits

OBJECTIVE

Few studies have utilised observation to investigate retained awareness when individuals with severe dementia interact with family members. Seeking evidence of retained awareness in those with severe dementia, interactive family visits in care homes were observed and analysed.

METHOD

Five family groups (14 individuals) completed 10/15-minute video recorded family interactions. Speech and non-speech interactions were analysed using Thematic Analysis.

RESULTS

One superordinate theme: Distinctive family bonds; overarched two subthemes, in-step and out-of-step describing positive and negative familial interactions. In-step interactions revealed family groups reciprocating social support, having fun together, and willing to go on the ride together. Out-of-step interactions characterised social frustration, non-reciprocity, and sidelining of members with dementia. Although awareness fluctuated, complex awareness was observed in the speech/non-speech expressions of those with dementia. In response, visitors appeared to treat those expressions and behaviours as understandable. Observed outcomes were out-of-step when visitors sought to retain the familiar and in-step when visitors sought to optimise all communication possibilities.

CONCLUSION

Video recorded family interactions and analysis revealed: (a) awareness was retained in the participants with severe dementia beyond assessed levels; and (b) Relational Social Engagement (RSE) occurred within family groups despite positive or negative interactions. Implications are discussed.